Wellpoint, Anthem to put higher premium on primary care

NORTH BAY -- WellPoint Inc., the nation's largest health insurance company and parent of Anthem Blue Cross, said it will pay physicians a higher reimbursement rate for primary care, a move aimed at reducing overall costs by rewarding preventative and quality care while hopefully addressing a nationwide physician shortage.

The new program increases a primary care physician's pay by about 10 percent. It will focus on both procedures and visits as well as "non-visit activities," Anthem spokesman Darrel Ng said.

Fewer physicians have entered into primary care because it pays far less than most medical specialties, a theme acutely felt in the Sonoma County and elsewhere in the North Bay. The issues is expected to come to head in 2014, when some 32 million more Americans -- about 45,000 in Sonoma County -- will enter the health care system via the Affordable Care Act. And a lack of access to basic primary care can lead to costly hospital visits for seemingly preventable illnesses or chronic diseases that go untreated, such as diabetes.

"It attempts to solve two problems -- use more primary care doctors and slow the increase of medical costs," Mr. Ng said of the new program. "The theory is that if we pay them more to provide better primary care, we better manage things like chronic disease and prevent emergency room visits, and therefore reduce costs in the system," Mr. Ng said. "The secondary benefit of this is that we recognize that come 2014, we will need more primary care doctors. By helping to pay them more, we hope to incentivize young med students to choose primary care."

About 46 percent of 1,071 doctors practice primary care in Sonoma County, and while the county has more physicians per capita than other regions of the state, there is "a significant local imbalance" between specialists and primary care physicians, according to a 2010 Primary Care Capacity Study by the Sonoma County Department of Health Services.

Indianapolis-based WellPoint, and by extension Anthem Blue Shield, also said it would increase its shared information with physicians, in an attempt to identify potentially costly trends it sees in certain patient populations.

"When you see millions of dollars in claims like we do, you can start to spot patterns," Mr. Ng said. Anthem could not provide specific statistics on how many North Bay doctors were in its network or how many patients were roughly treated throughout the region. Kaiser Permanente has approximately 61 percent of Sonoma County's insured population, according to a study by county Health Services.

The program is expected to fully implemented by the second half of 2012. WellPoint and Anthem are currently soliciting medical practices, large and small, to sign up for the voluntary program.

It could be a particular boon to smaller practices, which often lack the size and stature to negotiate high reimbursement rates from insurers, compared to large groups such as Sutter Health or the Marin-Sonoma IPA, for example.

WellPoint said physicians will be able to earn higher reimbursement rates through general increases to the regular fee-for-service model; payment for "non-visit" services currently not reimbursed, with a focus on compensation for plans for patients with complex and multiple conditions; and shared saving payments for quality outcomes and reduced costs.

The new program will also incorporate best practices from the company’s multiple medical home pilots.

Physicians who maintain certain levels of quality -- determined by organizations such as National Committee on Quality Assurance, the American Diabetes Association, and the American Academy of Pediatrics, among others -- can see an increase by as much as 30 percent to 50 percent of what they earn through the shared savings model, WellPoint estimates. The company hopes to reduce medical costs by as much as 20 percent by 2015.

“Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we’re committed to helping them achieve these quality and cost goals,” said Dr. Harlan Levine, WellPoint executive vice president, Comprehensive Health Solutions. “Primary care is the foundation of medicine, and it can and should be the foundation of our members’ health.”

WellPoint plans to begin implementing the patient-centered primary care program during the third quarter in select markets that show the greatest need based on health quality data, member outcomes and health care costs. The company’s goal is to implement the program across its primary care network by the end of 2014.